A Sad Indictment of Irish Social Care

Article by Professor Andy McDonnell

The recent HIQA report about the social care organisation Sunbeam House makes for very sobering reading. As a practitioner who has worked with both large and small organisations supporting people with intellectual disabilities and distressed behaviour for over 30 years, at times I experience déjà vu. Many who read the February 2025 report from HIQA may be reminded of the RTE documentary of 2014, Inside Bungalow 3, which exposed similar coercive practices. 

In the past I have described a ‘slippery slope’ to abuse (McDonnell, 2014), which often presents as signs of chaos in organisations, staffing shortages and people losing focus on day-to-day work practices. Many of the recurring themes in this report about the restrictive practices at Sunbeam House indicate what I would describe as ‘red flags.’ Staff shortages and the use of agency staff are now almost universal problems across the care sector. How can we develop meaningful relationships with individuals if people are only transitory in organisations?

Similarly, we must avoid focusing on staff training issues as an easy solution. Training is necessary, but not sufficient, to change organisational cultures. Research about organisations and their cultures does show that there is often a disconnect between managers and day-to-day staff. Professionals can also often be socially distant from the people they are supporting. Often, staff are asked to write a plan for someone about their behaviour, even though they may have had insufficient time to get to know them and their supporters. This can lead to an overfocus on behaviour plans rather than their implementation. 

Enforcing control upon others, through restraint, seclusion, or sanctions, is almost part of our human nature when faced with stressful and threatening situations. When frontline staff receive less support and direction about day-to-day practice, they will often fill the void themselves. I visited a service recently where a member of staff said to me, ‘You’ve really got to watch yourself with this one.’ This, to me, was symptomatic of a culture in that organisation where empathy and compassion was lacking. If we are to be serious about reducing restrictive practices, we cannot just do this using a top-down, policy-driven approach.

I have worked in Irish services for the best part of 30 years, and have had the privilege to work with some truly amazing practitioners. In the last 2 decades, the regulatory framework provided by HIQA has become stagnant in everyday practices. Don’t get me wrong, regulation is necessary. But so is an understanding that people are overwhelmed with information and policies, to the point that over-emphasis on this can result in cultures where frontline staff are scared to make day-to-day decisions. 

That being said, it’s not all doom and gloom. As a positive psychologist who works across different national boundaries, I spend a great deal of my time supervising staff to make decisions in collaboration with the people they support. It is important to maintain a positive approach to our day-to-day work. This means helping people who are supporting individuals with complex trauma to stay emotionally regulated.

My mantra is, ‘See the person, not the behaviour.’ Good people do good work if they are empowered to make day-to-day decisions. We also need to create cultures where we do not have to rely on ‘whistleblowing’ to put a stop to bad practice. If somebody sees something that is clearly wrong, they need to be able to provide feedback to their colleagues and not worry that they will be discriminated against in the future for doing so. We must remind ourselves that the vast majority of social care staff who support people in stressful situations do not practice coercion and control. These are people who are, in my experience, often emotionally connected to the people they are supporting. 

I have spent my career trying to get people to support individuals who are often described as complex or challenging. These individuals often have traumatic histories and attachment issues. People who support these individuals do need to be as emotionally regulated as they can be.

All of this requires individuals to be trained in approaches that are humanistic and person-centred. From a crisis management perspective, the Low Arousal Approach to managing behaviours - which includes demand reduction, the avoidance of punitive sanctions and rules, and the encouragement of the least restrictive environments - can be challenging for organisations.

We need to acknowledge a theory-practice gap between coaching and training in classrooms and the application of these principles in day-to-day practice. Central to all of this is that building transparent and trusting relationships creates a sense of safety. Reflective practice (McDonnell, 2019) is at the very heart of the Low Arousal Approach. If a person can acknowledge that from time to time, they may trigger a behaviour, that leads to the inevitable conclusion that they can also change their own behaviour to avoid doing so in the future. 

It is easy to focus on an organisation like Sunbeam House and not face the fact that some of the themes in the HIQA report could be common to many Irish social care organisations. Even more broadly, these issues are an international problem, not just an Irish one. To change cultures, we need to start with the basics of human compassion and kindness. Being person-centred can be difficult to achieve in organisations that are catering for large numbers of individuals. We have to get back to fundamental principles and focus on each person as unique and complex human beings. 

Professor Andrew McDonnell

Clinical Psychologist and CEO to Studio 3

May 2025